Treating the Lifelong Harm of Childhood Trauma

Image

Dr. Nadine Burke Harris, center, with a woman and two grandchildren at the Center for Youth Wellness in San Francisco.CreditBrant Ward/The San Francisco Chronicle

By David Bornstein

Jan. 30, 2018

Over the past decade, Dr. Nadine Burke Harris, the founder of the Center for Youth Wellness, in Bayview Hunters Point, San Francisco, has emerged as one of the country’s strongest voices calling for a national public health campaign to raise awareness and a sense of urgency about the devastating and potentially lifelong health effects of childhood trauma.

Since the original research on adverse childhood experiences, known as the ACE Study, was published in 1998, a growing body of evidence has indicated that severe or prolonged levels of childhood adversity (often measured in terms of an “ACE score” ranging from 0 to 10) are far more common and harmful than has been appreciated. Dr. Burke Harris, a pediatrician, has led in developing methods to screen and treat children and families suffering health problems attributable to what is known as toxic stress.

David Bornstein: What’s the most important takeaway from “The Deepest Well”?

Nadine Burke Harris: Childhood adversity literally gets under our skin and has the potential to change our health. The corollary is that it’s something we can do something about.

D.B.: What’s the difference between normal and “toxic” stress?

N.B.H.: We’re not talking about failing a test or losing at a sports match. We’re talking about threats that are severe or prolonged — things like abuse or neglect, or growing up with a parent who is mentally ill or substance-dependent. Our biological stress response is designed to save our lives from something threatening, and that’s healthy. The problem is that when the stress response is activated repeatedly it can become overactive and affect our brain development, our immune systems and even how our DNA is read and transcribed. High doses of stress hormones can inhibit the brain’s executive functioning and make it harder for kids or adults to exercise impulse control.

We see on M.R.I.s a shrinking of the hippocampus [a brain area important for memory and emotional regulation] and increased size of the amygdala, which is the brain’s fear center. This can make you hypervigilant — overly sensitive to threats or challenges. For individuals who are exposed to high doses of adversity in childhood, the pleasure and reward center of the brain — the ventral tegumental area, the part that is stimulated by cocaine, heroin, methamphetamine, tobacco, sex, high-sugar and high-fat foods — can be affected, so folks actually get less pleasure from these things. So they need higher doses, which leads to increases in risky behavior and substance dependence.

D.B.: Does toxic stress cause harm primarily because it makes people more likely to engage in unhealthy behaviors?

N.B.H.: High-risk behaviors only account for about 50 percent of the increased health risk. So even if you don’t drink, you don’t smoke, you don’t do all that stuff, you’re still at increased risk for things like heart disease and chronic obstructive pulmonary disease. There are two reasons. One is the impact of early adversity on the immune system. What we see is increased chronic inflammation and risk for autoimmune diseases like lupus or rheumatoid arthritis or asthma. A child with four or more ACEs has double the risk for asthma as one with no ACEs. The other one is the impact on our epigenetic regulation: the way our DNA is read and transcribed. Telomeres are these bumpers on the ends of our DNA and they protect our DNA from wear and tear. A lot of things accelerate the rate at which our telomeres get shortened, which leads to premature cellular aging. It can be pollutants or smoking tobacco. But one important thing is exposure to high doses of adversity in childhood.

D.B.: What’s the scope of this problem?

N.B.H.: Two-thirds of Americans have been exposed to one significant adverse childhood experience, and between 13 and 17 percent have been exposed to four or more. We know that being exposed to high doses of childhood adversity dramatically increases the risk for seven of the 10 leading causes of death in the United States.

D.B.: How did you come to understand it?

N.B.H.: I had so many children being referred to me for evaluation of A.D.H.D., sent in by teachers or principals or counselors. “This child is having terrible behavior problems. Lots of difficulties with impulse control. Can you put him on Ritalin?” But when I did a thorough history and physical exam, for most of my patients I could not make the diagnosis of A.D.H.D. The diagnostic criteria for attention-deficit disorder says it can’t be caused by anything else. For my kids there was an extremely strong thread: So many were being exposed to very high doses of adversity. At the same time, I was seeing patients like a girl who I was treating for asthma. When I asked, “What are your asthma triggers?” her mom said, “I noticed that my daughter’s asthma acts up every time her dad punches a hole in the wall.” And then I got to the patient that I talk about in the book, Diego, a 7-year-old boy who seemed to have stopped growing after a sexual assault at age 4. For me, that was the case that made me stop in my tracks and say there is something else going on here and I need to get to the bottom of it.

D.B.: Can you say more about Diego?

N.B.H.: Diego had growth failure, but he also had asthma, eczema and behavior problems. The frame shift for me was instead of doing the standard treatment for each of his four diagnoses, I asked, “Is it possible that the trauma that he’s been exposed to could be the underlying cause of all these problems?” When I consulted hormone specialists, I was told that’s likely the case. O.K., well, then, the thing we need to treat is the trauma.

That’s when I began diving into the research literature. In 2008, I came across the ACE Study, which had been published in 1998. I was absolutely shocked that I had never heard about it and that as a doctor I was never trained on it. And so for me that began a mission to translate the science into something useful for patients.

D.B.: What needs to happen?

N.B.H.: No. 1, universal screening. The best tools we have right now are early detection and prevention. Studies show that when kids received early high quality intervention, their brain scans ended up looking more like those of children who had never been maltreated than children who had been maltreated. Ultimately, every pediatrician in America needs to be screening for ACEs.

D.B.: How do you make screening doable?

N.B.H.: At our center, we screen for the number of ACEs, but we don’t ask folks to identify each individual one. We recognize that these are sensitive questions to ask in a clinical setting. But we need to screen the entire population, and the only way to screen everyone is in primary care. If you’re waiting until you get to a mental health practitioner, you’re going to be too late, and a lot of kids will be missed. Our screening can be done in three minutes or less. It’s quick to interpret. A doctor can look at it and say this child is at low risk, moderate risk or high risk of having a toxic stress physiology. For me it’s no different than laying a stethoscope on a patient’s chest.

D.B.: What are the treatment implications?

N.B.H.: One of the key ingredients for keeping the body’s stress response out of the toxic stress zone is the presence of a healthy buffering caregiver. So we need to educate parents and caregivers about the impact a child’s environment and exposures may be having on their health. We also know that if a caregiver is able to self-regulate, their kids have much better outcomes. Good old-fashioned mental health care really does help. In research studies, certain types of interventions, including child-parent psychotherapy, can help to normalize cortisol levels and get the body’s stress response back on track. We designed our services at the Center for Youth Wellness with this science in mind. We provide mental health and wellness services to either the child or the parent. It’s really important that we do this two-generational work.

D.B.: What else is helpful?

N.B.H.: The six core pieces that are key to addressing the biology of toxic stress are sleep, exercise, nutrition, mindfulness, mental health and healthy relationships. Certain diets support a healthy immune system and neuroplasticity. And when you exercise, it helps to metabolize stress hormones and release other hormones that counteract effects of stress and also support cardiovascular health and reduce chronic inflammation.

D.B.: What social problems can this science help us understand better?

N.B.H.: Substance dependence: An individual with four or more ACEs is 10 times more likely to be an IV drug user as someone with no ACEs. Education and underperforming schools is a big one: When we did a chart review of 702 patients, we found that if a child had an ACE score of 4 or more, they were 32.6 times more likely to have learning or behavior problems. The justice system: When you look at the proportions of folks in our jails who have high adversity, especially our juvenile incarcerated population, we’re talking about greater than 90 percent.

A lot of my adolescent patients have been told that they’re screwups. When I say to them, “Because of what you’ve experienced, your body makes more stress hormones than the average person, and that can look and feel like being quick to anger, or having difficulty controlling your impulses, or getting sick easily when you feel overwhelmed.” And I will tell you the look on their faces when they say, “Wait, you mean I’m not crazy?” That literally is the No. 1 response I get.

Being able to understand that makes a world of difference. And folks can begin to develop a skill set for helping to manage their stress response. And they end up getting into less threatening or challenging situations, and oftentimes for parents, they’re able to make healthier choices for their kids, and that is where we break the intergenerational cycle of adversity.

D.B.: What do you hope the book can achieve?

N.B.H.: ACEs and toxic stress are a public health crisis. When you look at any successful public health campaign, it starts with raising awareness, so that people understand there is a problem to begin with. ACEs cross every line — racial, ethnic, geographic, gender, socio-economic. Today most parents are aware that secondhand smoke is really bad for kids, everyone has to wear a seatbelt, and lead is a neurotoxin. We need a national public campaign about toxic stress. We need to be shouting this from the rooftops.